Operation Door Hanger--Working Across Sectors to Raise Investment in Public Health Preparedness

State: MO Type: Model Practice Year: 2010

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Under the CDC Public Health Cooperative Agreement for Public Health Emergency Planning and Preparedness (PHEPP) City Readiness Initiative (CRI), LPHA’s of all sizes are challenged to rapidly dispense preventive pharmaceuticals to an entire target population within 48 hours in the event of a terrorist attack or other public health emergency. The 33,125 residents of Lafayette County are dependent upon a public health staff of only eight full-time and four part-time employees. Most dispensing methodologies are designed around a medical model where affected citizens report to Point of Dispensing (POD) locations to be screened and given the medications indicated. Given the limited staff and even volunteers available, to conduct this type of operation, preparedness staff at LCHD (with administrative support) designed and scheduled a drill to be conducted April 8, 2009 to evaluate their capabilities, utilizing community partnerships to test an alternate dispensing methodology.

The overarching goal of the exercise was to utilize an alternate dispensing methodology to reach as many of the roughly 12,000 households in the county within the five hour time limit of the exercise, without straining public health personnel resources by using relationships with community emergency management agencies, chambers of commerce, school districts, media, private businesses, and volunteers. The agency with the primary role in a mass dispensing operation is the local public health agency. However, given the limited staff resources of most LPHA’s to accomplish the ambitious requirements of the CRI mass dispensing tasks, methodologies other than the medical (POD) strategy must be developed. In exploring other options, LCHD recognized that the majority of the county’s population was captured within an incorporated area with an acting EMD. LCHD also believed that each EMD was in the best position to know the resources available to him in his respective community and what volunteer and professional groups to enlist in the effort.

The exercise was designed to simulate a mass prophylaxis operation. Several alternate dispensing methods had been suggested or described in written plans, but to the knowledge of LCHD staff, never tested. LCHD staff believed that a test of such an alternate methodology could provide valuable data that would strengthen and improve existing public health and community emergency response plans, base on actual results rather than speculation or mathematical models. The drill not only demonstrated that this approach could be successfully implemented as an alternate dispensing methodology for emergency distribution of pharmaceuticals, but that there is potential in using a similar methodology for distributing emergency communications in a large-scale disaster. The successes of this exercise and strategy were overwhelmingly encouraging for agencies with few personnel resources to devote to the large task of the CRI objective of reaching 100% of their population in 48 hours. The exercise proved that this “modified postal” model could be a viable option for health departments, especially those with few personnel. Another opportunity taken during this exercise was to gather information about the likelihood of drug interactions to the SNS medications, were the “push” type dispensing methodology chosen over the medical model. A survey was developed to collect basic demographic data about a household (how many adults, children), structured based on the health screening form used for medical model PODs, and placed randomly in 6,000 of the 12,000 bags to be distributed. 551 surveys (9%) were returned. Results indicated that roughly 19% of recipients would have a potential contraindication to Doxycycline, and 22% to Ciprofloxacin. The reason ranged from current antibiotic use or interaction with prescriptions being taken, to being related to children less than 9 years of age living in 13% of the households. Results of the study and

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Lafayette County Health Department
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Operation Door Hanger--Working Across Sectors to Raise Investment in Public Health Preparedness
Under the CDC Public Health Cooperative Agreement for Public Health Emergency Planning and Preparedness (PHEPP) City Readiness Initiative (CRI), LPHA’s of all sizes are challenged to rapidly dispense preventive pharmaceuticals to an entire target population within 48 hours in the event of a terrorist attack or other public health emergency. The 33,125 residents of Lafayette County are dependent upon a public health staff of only eight full-time and four part-time employees. Most dispensing methodologies are designed around a medical model where affected citizens report to Point of Dispensing (POD) locations to be screened and given the medications indicated. Given the limited staff and even volunteers available, to conduct this type of operation, preparedness staff at LCHD (with administrative support) designed and scheduled a drill to be conducted April 8, 2009 to evaluate their capabilities, utilizing community partnerships to test an alternate dispensing methodology. The overarching goal of the exercise was to utilize an alternate dispensing methodology to reach as many of the roughly 12,000 households in the county within the five hour time limit of the exercise, without straining public health personnel resources by using relationships with community emergency management agencies, chambers of commerce, school districts, media, private businesses, and volunteers. The agency with the primary role in a mass dispensing operation is the local public health agency. However, given the limited staff resources of most LPHA’s to accomplish the ambitious requirements of the CRI mass dispensing tasks, methodologies other than the medical (POD) strategy must be developed. In exploring other options, LCHD recognized that the majority of the county’s population was captured within an incorporated area with an acting EMD. LCHD also believed that each EMD was in the best position to know the resources available to him in his respective community and what volunteer and professional groups to enlist in the effort. The exercise was designed to simulate a mass prophylaxis operation. Several alternate dispensing methods had been suggested or described in written plans, but to the knowledge of LCHD staff, never tested. LCHD staff believed that a test of such an alternate methodology could provide valuable data that would strengthen and improve existing public health and community emergency response plans, base on actual results rather than speculation or mathematical models. The drill not only demonstrated that this approach could be successfully implemented as an alternate dispensing methodology for emergency distribution of pharmaceuticals, but that there is potential in using a similar methodology for distributing emergency communications in a large-scale disaster. The successes of this exercise and strategy were overwhelmingly encouraging for agencies with few personnel resources to devote to the large task of the CRI objective of reaching 100% of their population in 48 hours. The exercise proved that this “modified postal” model could be a viable option for health departments, especially those with few personnel. Another opportunity taken during this exercise was to gather information about the likelihood of drug interactions to the SNS medications, were the “push” type dispensing methodology chosen over the medical model. A survey was developed to collect basic demographic data about a household (how many adults, children), structured based on the health screening form used for medical model PODs, and placed randomly in 6,000 of the 12,000 bags to be distributed. 551 surveys (9%) were returned. Results indicated that roughly 19% of recipients would have a potential contraindication to Doxycycline, and 22% to Ciprofloxacin. The reason ranged from current antibiotic use or interaction with prescriptions being taken, to being related to children less than 9 years of age living in 13% of the households. Results of the study and
Under the CDC Public Health Cooperative Agreement for Public Health Emergency Planning and Preparedness (PHEPP) City Readiness Initiative (CRI), LPHA’s of all sizes are challenged to rapidly dispense preventive pharmaceuticals to an entire target population within 48 hours in the event of a terrorist attack or other public health emergency. The 33,125 residents of Lafayette County are dependent upon a public health staff of only eight full-time and four part-time employees. Most dispensing methodologies are designed around a medical model where affected citizens report to Point of Dispensing (POD) locations to be screened and given the medications indicated. Given the limited staff and even volunteers available, to conduct this type of operation, preparedness staff at LCHD (with administrative support) designed and scheduled a drill to be conducted April 8, 2009 to evaluate their capabilities, utilizing community partnerships to test an alternate dispensing methodology. This practice addresses the issue of unavailability of sufficient public health workforce and volunteers recruited and trained by an LPHA to accomplish mass dispensing operations under the City Readiness Initiative directive of reaching 100% of a target population within a 48 hour time frame. By increasing investment (of personnel and resources) in public health emergency response from other sectors in the community, a huge burden is lifted from the local public health agency not only to accomplish mass dispensing objectives, but to maintain public health infrastructure during times of emergency.Lessons learned from past exercises where mass dispensing methodologies were tested indicated that local public health's capability to staff Points of Distribution using a medical model are not likely to be sufficient, nor effective if distribution must be complete within a 48 hour time frame. In exploring other dispensing methodologies, the alternate methodology of "pushing" medicine out to the population appeared most promising in achieving this formidable CRI task. A review of after action reports indicated that while staffing medical model Points of Distribution remained a concern, tests (exercises) of other methodologies were scarce, if not non-existent. The testing of this alternate dispensing methodology is the first step in exploring other mass dispensing methodologies to identify strengths and weaknesses of such potential methodologies prior to having to implement them during an actual event. This could be considered a "modified postal” alternate dispensing methodology. In this methodology, volunteers replace USPS personnel as carriers, somewhat resolving the issue of security escorts for each mail carrier, leaving the security piece up to the local EMD. In this exercise, patrol units were assigned to groups of volunteers, not one-on-one, and no safety breeches or incidents occurred. A review of literature and after action reports on mass dispensing indicated that few if any exercises have been conducted using alternate dispensing methodologies on this scale (county-wide). The process used was a search for literature about mass dispensing operations, especially the use of alternate dispensing methodology, and a review of After Action Reports of various jurisdictions who have tested Mass Dispensing methodologies through FEMA’s Lessons Learned Information Sharing System (LLIS.gov) and the National Association of County and City Health Officials (NACCHO). With regard to the LLIS.gov library, there was a notable lack of evidence that much had been tested in the area of alternate dispensing methodologies, as well as information related to the number of adverse events a jurisdiction could anticipate if a non-medical model methodology was used. Of the 1,964 after action reports submitted to this library, 48 covered a variety of issues related to operating medical model Points of Distribution (PODs), but not alternate dispensing models. NACCHO published a
Agency Community RolesThe agency with the primary role in a mass dispensing operation is the local public health agency. However, given the limited staff resources of most LPHA’s to accomplish the ambitious requirements of the CRI mass dispensing tasks, methodologies other than the medical (POD) strategy must be developed. In exploring other options, LCHD recognized that the majority of the county’s population was captured within an incorporated area with an acting EMD. LCHD also believed that each EMD was in the best position to know the resources available to him in his respective community and what volunteer and professional groups to enlist in the effort. These volunteers ranged from on-duty law enforcement and fire services to off-duty professionals, youth and church groups. The total LCHD staff investment for the operation was two staff members, who for the purpose of the exercise, functioned in the Incident Command Structure (ICS); one as overall IC, the other as a ‘runner.’ All other LCHD staff went about “business as usual” that day and no normal health department operations were interrupted. Within a four hour forty-five minute time frame, packets of emergency information, simulating medications, were distributed to approximately 10,000 households (roughly 83% of the target). In order for local public heatlh agencies to successfully protect the communities they serve when mass prophylaxis is required, the support and engagement of local emergency management and other community response and service sectors will be critical. The time to build, increase community investment, and educate stakeholders about this process is prior to an actual event. Engagement of these partners in public health emergency response exercises is key to reinforcing that they also have responsibility for successful emergency response in their communities. This exercise revealed that these partners are willing to be part of that planning, testing, and evaluation process. Costs and ExpendituresDevelopment of this exercise was in accordance with Homeland Security Exercise and Evaluation Program (HSEEP) principles. Exercise development was accomplished using the existing LEPC committee structure and therefore did not require the services of an exercise design contractor. Approximate investment of LCHD staff time (for the PHEPP Planner) was 300 hours over six months. Sectors represented in the exercise included: Elected and appointed officials, Law Enforcement, other governmental agencies (School districts), community service organizations, private businesses, churches, and citizen volunteer groups (amateur radio, CERT teams). Existing group meeting calendars (councils, school boards, LEPC) were used as an opportunity for community engagement rather than scheduling additional meetings. A variety of communications strategies were employed to get the word out to citizens in advance of the exercise. These included not only the more traditional media (radio & newspaper), but email, fax, text casting, school websites, and even the National Weather Service announcement feature were utilized. To prepare exercise materials, volunteers were used to assemble plastic bags printed with the Health Department logo containing free emergency preparedness resources and literature. It took approximately 15 to 20 volunteers 54 man hours to accomplish this. The bags were then divided according to the population estimates for each incorporated area and prepositioned at those command posts. Player briefings were held in each community at that command post which addressed exercise play rules and safety issues. Volunteer Amateur Radio Operators (HAM) ran the county-wide communications for the exercise. The HAM operators’ plain language approach accommodated the diverse volunteer groups being used to deploy the bags nicely. Costs to develop and conduct this exercise were modest considering the scale of the exercise. Actual expenses incurred by LCHD were for printed materials and the plastic bags for distribution, and the time invested by the LCHD planner. Costs for supplies: bags, envelopes, P.O. mailing fee, printing, paper, paper clips, volunteer meeting meals $3,577.57; Mileage $137.00 (all in-county). The most impressive aspect of this activity was that it was done within the existing resources of this small, rural health department. A dollar amount was not calculated for volunteer hours and in-kind support; however, the point of the exercise was to explore gaining the investment from community partners in manpower vs. dollar amounts to extend the capacity of the local public health agency to achieve CRI goals. All costs to LCHD for this exercise were covered by the CDC Cooperative Agreement contract for Public Health Emergency Planning & Preparedness. In kind costs would include mostly manpower provided by the partnering agencies who supplied emergency management and volunteer support. ImplementationThe specific tasks for achieving the goals and objectives for this practice are outlined in the Exercise Design process. Key tasks taken in the six month timeframe included: 1) forming a design team; 2) Using as many existing committee structures as possible to give input to the exercise design; 3) establishing the goals and objectives, scope of the exercise, and rules for play (follow HSEEP templates); 4) Development of supporting exercise materials—in this case the simulation materials and the survey; 5) Incorporate just in time training and player briefings into the process; 6) Establish time frames for collection and analysis of data and evaluations; 7) compile after action report. In the case of this exercise, allowing sufficient time for designing an exercise of this scope is key, and HSEEP recommendations should be followed if possible. However, the planning process for this exercise was a bit shortened in regard to HSEEP guidelines. The design process for this exercise was completed within six months. The design team must be established early on (within the first 30 days) as they will guide the process. Using existing committee structures resulted in exercise planning meetings occurring about weekly in the early stages to monthly. The development of the supporting materials included ordering and printing, and was done within one to two months inside the six month process. Player briefings were done just in time for the exercise, but a substantial amount of community and stakeholder education took place on an ongoing basis throughout the six month planning process, through phone calls, emails, website postings, and media releases. Collection of the data and evaluation of the exercise was concluded within 60 days following the exercise. Total process from start (November) to finish (June) about seven months.
To determine how many of 12,000 households in the county could be reached within the five hour time limit of the exercise, using relationships with community emergency management agencies, chambers of commerce, school districts, media, private businesses and volunteers to determine viability as an alternate dispensing method. Test of alternative dispensing method for reaching acceptable percent of population toward CRI objectives. Participation by incorporated areas in the county was 14 of 17 (82%); Meetings were held with elected officials (mayors & city councils) in each incorporated area prior to exercise (within a six month time frame); meetings with local emergency planning committees (LEPC's) were held prior to exercise date; contact was made with other key agencies not represented by elected official groups or LEPC's prior to exercise date (seven school districts, county law enforcement). Meeting minutes were collected which also served to document just in time training for the event. US Census data was used to estimate the total population of the county and approximate number of households represented to establish the target of 12,000 households. The bags to simulate the medication being dispensed to the households were then counted and assembled by volunteers. Bags were further subdivided by incorporated area and counted out as they were given by command post staff to teams to distribute, counted back in if any were left after delivery was complete. The count at the end of the exercise indicated that roughly 80% of the 12,000 households targeted received bags. Meeting minutes and other documentation was collected by LCHD planning staff as the meetings were held. The simulation materials were counted by LCHD staff and volunteers during assembly, and then again by field command post staff and volunteers during distribution. Final numbers were reviewed by LCHD planning and administrative staff. The Homeland Security Exercise and Evaluation Program format was used to create a comprehensive After Action Plan (HSEEP compliant) which discusses the design of the exercise, lessons learned and corrective actions to be implemented based on the outcomes of the exercise. The AAR is available on the LCHD web site. Participants also completed evaluations and these results are contained in the AAR. The outcome of this exercise indicated that utilizing this alternative dispensing model has great possibilities for the short term with long term potential for use by rural LPHA's in achieving CRI goals for reaching 100% of a population in 48 hours.To estimate the number of adverse reactions that could be expected in the target population if a push type dispensing methodology were used over a medical model POD type methodologyFor this objective, the Missouri Department of Health and Senior Services Bureau of Health Informatics was contacted by LCHD to verify the number of surveys that would need to be distributed in the target population to assure statistical validity and reliability. LCHD then consulted with a partnering company (NEXGENYSIS) that has designed throughput software for the medical model PODs and a staff member with Mid America Regional Council (MARC) who had expertise in bio-statistics. A survey was developed based on the health assessment forms that would be used in a medical model POD. This was accomplished in three meetings. These activities were all completed within the six month exercise design time frame. Following the exercies LCHD consulted with NEXGENYSIS and MARC representatives to compile the data from the surveys and publish a final report, which is available separately or is included in the AAR.The random sample survey was distributed in a portion of the simulation material bags for the exercise. Individuals also received a cover letter explaining the survey and instructions for completing and returning it. Drop boxes at city government offices were used to collect the surveys, and households could also choose to
Because this practice involves community emergency response agencies, there are existing requirements for conducting exercises that test plans. This is one aspect that ensures commitment at least for those agencies who must meet these requirements. As a result of this exercise, however, LCHD has expanded and enhanced relationships with sectors who have not previously had much involvement in this process, such as school district administrations, faith based groups, the private business community, and the media. Now that they have been engaged and seen the very positive results of this exercise, they are likelier to be interested parties in future operations. The staff at LCHD will be challenged to maintain the level of interest from these atypical public health emergency response partners. As LCHD plans for future exercises built on the strengths and weaknesses identified in efforts such as this one, we will continue to engage these partners and educate them about the role of the health department and other sectors in responses to community wide public health emergencies. So long as our agency continues to receive funding for meeting our public health emergency planning and preparedness objectives including CRI initiatives, we feel that our other sectors are willing to contribute resources, if not financial, then at least manpower, toward the goal of achieving more comprehensive community preparedness.
 
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